Further increases in rural suicide in young Australian adults: Secular trends, 1979–2003

Protective Factors against Self-Harm and Suicidality among Australian Indigenous Adolescents: A Strengths-Based Analysis of the Longitudinal Study of Indigenous Children

Background: Understanding and encouraging social and emotional well-being (SEWB) among Indigenous adolescents is vital in countering the impacts of colonisation and intergenerational trauma. As self-harm and suicidality are considered markers of poor SEWB among Indigenous communities, we aimed to identify the individual-level and community-level factors protecting Indigenous adolescents from self-harm and suicidality. Methods: Data came from Footprints in Time—The Longitudinal Study of Indigenous Children (waves 10 and 11), conducted among Indigenous families across Australia. A strengths-based analysis fitted multilevel logistic regression to explore associations with factors proposed as protective against self-reported self-harm and suicidality among Indigenous adolescents. Results: Our study cohort included 365 adolescents with complete data for the variables of interest. Adolescents had a mean (SD) age of 14.04 (0.45) years and a sex ratio of almost 1:1, and most were attending school (96.2%). Previous self-harm was reported by 8.2% (n = 30); previous suicidality was reported by 4.1% (n = 15). Individual-level factors protecting against self-harm and suicidality were being male, living in a cohesive family, and having low total Strengths and Difficulty Questionnaire scores (p < 0.05 for all). Residing in major cities compared with regional/remote areas was protective against self-harm (OR 5.94, 95% CI 1.31−26.81). Strong cultural identity was not found to be a protective factor against self-harm and/or suicidality in the sample. Conclusions: This study identified key individual- and community-level factors that can protect Australian Indigenous adolescents against self-harm and suicidality, particularly family cohesion. Identifying strengths for this at-risk population can inform prevention strategies, particularly for rural living adolescents with high distress.

Inequalities of Suicide Mortality across Urban and Rural Areas: A Literature Review

Suicide mortality is a major contributor to premature death, with geographic variation in suicide rates. Why suicide rates differ across urban and rural areas has not yet been fully established. We conducted a literature review describing the urban–rural disparities in suicide mortality. Articles were searched in five databases (EMBASE, PubMed, PsychINFO, Scopus, and Web of Science) from inception till 26 May 2021. Eligible studies were narratively analyzed in terms of the urban–rural disparities in suicides, different suicide methods, and suicide trends over time. In total, 24 articles were included in our review. Most studies were ecological and cross-sectional evidence tentatively suggests higher suicide rates in rural than in urban areas. Men were more at risk by rurality than women, but suicide is in general more prevalent among men. No obvious urban–rural pattern emerged regarding suicide means or urban–rural changes over time. Potential suicidogenic explanations include social isolation, easier access to lethal means, stigmatization toward people with mental health problems, and reduced supply of mental health services. For research progress, we urge, first, individual-level cohort and case-control studies in different sociocultural settings. Second, both rurality and urbanicity are multifaceted concepts that are inadequately captured by oversimplified typologies and require detailed assessments of the sociophysical residential environment.

Suicide in rural Australia: A retrospective study of mental health problems, health-seeking and service utilisation

Background

Suicide rates are higher in rural Australia than in major cities, although the factors contributing to this are not well understood. This study highlights trends in suicide and examines the prevalence of mental health problems and service utilisation of non-Indigenous Australians by geographic remoteness in rural Australia.

Methods

A retrospective study of National Coronial Information System data of intentional self-harm deaths in rural New South Wales, Queensland, South Australia and Tasmania for 2010–2015 from the National Coronial Information System.

Results

There were 3163 closed cases of intentional self-harm deaths by non-Indigenous Australians for the period 2010–2015. The suicide rate of 12.7 deaths per 100,000 persons was 11% higher than the national Australian rate and increased with remoteness. Among people who died by suicide, up to 56% had a diagnosed mental illness, and a further 24% had undiagnosed symptoms. Reported diagnoses of mental illness decreased with remoteness, as did treatment for mental illness, particularly in men. The most reported diagnoses were mood disorders (70%), psychotic disorders (9%) and anxiety disorders (8%). In the six weeks before suicide, 22% of cases had visited any type of health service at least once, and 6% had visited two or more services. Medication alone accounted for 76% of all cases treated.

Conclusions

Higher suicide rates in rural areas, which increase with remoteness, may be attributable to decreasing diagnosis and treatment of mental disorders, particularly in men. Less availability of mental health specialists coupled with socio-demographic factors within more remote areas may contribute to lower mental health diagnoses and treatment. Despite an emphasis on improving health-seeking and service accessibility in rural Australia, research is needed to determine factors related to the under-utilisation of services and treatment by specific groups vulnerable to death by suicide.

Influence of contextual factors on death by suicide in rural and urban settings

PURPOSE

To examine the association between contextual factors, represented by geographic and community health variables, and suicide among rural and urban Department of Veterans Affairs health care users (VA users).

METHODS

We performed a retrospective cohort study of 12,700,847 VA users between 2003 and 2017. We assigned contextual factors based on individuals' home address at the ZIP Code (area deprivation), county (sunlight exposure, altitude, and community health), and state level (firearm ownership), using publicly available data sources. We grouped contextual factors by quintiles or prespecified thresholds, depending on the nature of each variable. We obtained mortality data from the National Death Index. We measured the effect of living in a place with the highest versus lowest level of each contextual factor on odds of suicide using logistic regression, adjusting for individual compositional factors abstracted from VA electronic medical records data. We used random forest modeling to build prediction models for suicide based on contextual factors among rural and urban veterans.

FINDINGS

Almost all contextual factors we examined were significantly associated with suicide among rural and urban VA users, even after adjusting for individual compositional factors. However, no contextual variables were strong protective or risk factors (0.5<OR>2.0), and prediction models leveraging these contextual factors had poor accuracy among both rural (0.51, 95% CI: 0.48-0.54) and urban (0.53, 95% CI: 0.51-0.55) VA users.

CONCLUSIONS

A wide variety of contextual factors is significantly associated with suicide among rural and urban VA users. However, the factors we measured contributed very little to individual-level suicide risk.

Rural-urban differences in suicide attempts and mortality among young people in northern Sweden, 1998-2017: A register-based study

Aim: The aim of this study was to assess trends in suicide attempts and mortality between 1998 and 2017 by residential area and gender among northern Swedish youths. Methods: Events of suicide attempts and deaths for each municipality in the four counties of the northern Swedish region, stratified by gender, were retrieved for each year from 1998 to 2017. All cases identified within the registers with the diagnostic codes X60-X84 or Y10-Y34 (International Classification of Diseases, 10th revision) for individuals aged 15-24 years were included. Place of residence at municipal level was categorized into three groups: rural - municipalities with a population of <10,000 inhabitants; semi-rural - those between 10,000 and 50,000; and urban - those with >50,000 inhabitants. Results: The rates of attempted suicides in the northern region were higher in both men and women than in Sweden, while the rates of suicide deaths were slightly higher in young men but similar in young women compared to the national averages. Overall, the risk of suicide attempts was higher in semi-rural municipalities compared to urban ones, particularly among women. A significantly higher risk of mortality was also observed for men and women in semi-rural municipalities, but only in the period 2010-2013. Conclusions: The high rates of attempted and completed suicides among youth in northern Sweden and the higher risks in rural and semi-rural municipalities need close attention. The implementation of suicide prevention programs, especially in rural and semi-rural municipalities, should be intensified.

Does population density moderate suicide risk? An Italian population study over the last 30 years

Background.

The relationship between population density and suicide risk remains unclear. While urbanization is associated with greater risk for psychopathology, higher suicide rates have been reported in rural areas. We examined population density and suicide in the Italian population in the last 30 years.

Methods.

The Italian National Institute of Statistics databases of the Italian population aged 15 years and older (52.4 million in 2016) were used to compute age-adjusted annual total mortality and suicide rates for the years 1985–2016. According to the European Union statistical office (EUROSTAT) criteria, municipalities were classified into densely populated areas, intermediate density areas, or thinly populated areas. Rate ratios (RRs) were computed by sex, age, and geographical area, using densely populated areas as reference.

Results.

Total mortality was not associated with population density. In males, suicide rate increased with decreasing population density (RR = 1.17, 95% confidence interval [CI]:1.08–1.28, in intermediate population areas, and RR = 1.32, 95% CI: 1.20–1.45, in thinly populated areas, in 2016). This inverse relationship was found across age, geographical areas, and consecutively over 22 years (1994–2016). In females, no significant difference was detected (RR = 0.96, 95% CI: 0.82–1.13 in intermediate density areas and RR = 1.02, 95% CI: 0.85–1.22 in thinly populated areas). Hanging was the most common suicide method among males, more frequent in thinly (58.8%) than intermediate (53.2%) or densely (41.4%) populated areas.

Conclusions.

A consistent and temporally stable inverse relationship between population density and suicide was found in the male, but not female, population. Men may be more vulnerable to adverse social and economic factors associated with lower population density.

Suicídio em Portugal: um retrato do país

RESUMO Objetivo Identificar padrões de tendências do suicídio registrado em Portugal, tendo em conta um conjunto de variáveis socioeconômicas e demográficas entre os anos 2007 e 2014, de modo a obter uma visão geral desse flagelo em Portugal. Métodos Recorrendo a dados do Instituto Nacional de Estatística (INE) e do Sistema de Informação dos Certificados de Óbito (SICO), foi analisado o suicídio segundo a categoria do CID-10 (Classificação Internacional de Doenças), examinando-se as incidências por gênero, faixa etária e região. Resultados Os mais acometidos pelo suicídio são homens (54,8%), com idade superior a 75 anos (30,9%), e ele ocorre nas zonas economicamente mais desfavorecidas. A mortalidade por suicídio mais elevada encontra-se na região do Alentejo (12,8%). Conclusão A mortalidade por suicídio continua a crescer em Portugal e varia em função do gênero e idade, sendo mais elevada nas regiões do Centro e Sul. É necessária uma estratégia de acompanhamento e de prevenção no âmbito da ação social e dos cuidados de saúde, com importantes variações regionais, e maior vigilância sobre a comercialização ilegal de armas de fogo e de pesticidas.

Urban-rural inequalities in suicide mortality: a comparison of urbanicity indicators

Background

Urban–rural disparities in suicide mortality have received considerable attention. Varying conceptualizations of urbanity may contribute to the conflicting findings. This ecological study on Germany assessed how and to what extent urban–rural suicide associations are affected by 14 different urban–rural indicators.

Methods

Indicators were based on continuous or k-means classified population data, land-use data, planning typologies, or represented population-based accessibility indicators. Agreements between indicators were tested with correlation analyses. Spatial Bayesian Poisson regressions were estimated to examine urban–rural suicide associations while adjusting for risk and protective factors.

Results

Urban–rural differences in suicide rates per 100,000 persons were found irrespective of the indicator. Strong and significant correlation was observed between different urban–rural indicators. Although the effect sign consistently referred to a reduced risk in urban areas, statistical significance was not universally confirmed by all regressions. Goodness-of-fit statistics suggested that the population potential score performs best, and that population density is the second best indicator of urbanicity. Numerical indicators are favored over classified ones. Regional planning typologies are not supported.

Conclusions

The strength of suicide urban–rural associations varies with respect to the applied indicator of urbanicity. Future studies that put urban–rural inequalities central are recommended to apply either unclassified population potentials or population density indicators, but sensitivity analyses are advised.

Electronic supplementary material

The online version of this article (10.1186/s12942-017-0112-x) contains supplementary material, which is available to authorized users.

Patterns and predictors of help-seeking contacts with health services and general practitioner detection of suicidality prior to suicide: a cohort analysis of suicides occurring over a two-year period

BACKGROUND

Contact with primary care and psychiatric services prior to suicide may be considerable, presenting opportunities for intervention. However, there is scant knowledge on the frequency, nature and determinants of contact.

METHOD

Retrospective cohort study-an analysis of deaths recorded as suicide by the Northern Ireland Coroner's Office linked with data from General Practice patient records over a 2 year period

RESULTS

Eighty-seven per cent of suicides were in contact with General Practice services in the 12 months before suicide. The frequency of contact with services was considerable, particularly among patients with a common mental disorder or substance misuse problems. A diagnosis of psychiatric problems was absent in 40% of suicides. Excluding suicide attempts, the main predictors of a noted general practitioner concern for patient suicidality are male gender, frequency of consultations, diagnosis of mental illness and substance misuse.

CONCLUSIONS

Despite widespread and frequent contact, a substantial proportion of suicidal people were undiagnosed and untreated for mental health problems. General Practitioner alertness to suicidality may be too narrowly focused.

Changes in South Korean urbanicity and suicide rates, 1992 to 2012

OBJECTIVES

Studies have highlighted the association between the degree of urbanicity and spatial disparities in suicide, but few have evaluated its changes across time. We explored the geospatial trends of suicide in South Korea from 1992 to 2012, and their relationship to the nation's evolving urbanicity.

SETTING

South Korea.

PRIMARY OUTCOME MEASURES

Age-sex-specific suicide rate.

RESULTS

Suicide rates increased in all regions of South Korea during the study period. Controlling the effects of age and sex, there was an overall inverse relationship between the degree of urbanicity and regional suicide rates. These associations were, however, attenuated across the periods, as there were smaller increases in suicide rates in mid-sized urban regions as compared to larger cities and to rural areas. Increases over time in the suicide rates among youth and working-age adults were greater in large urban centres and in rural regions. For elders, the increase was far greater in rural regions.

CONCLUSIONS

The association of urbanicity and the geospatial pattern of suicide in South Korea was a dynamic process and varied by age groups across the course of two decades. Internal migration and related social processes most likely contributed to these changes.

Suicide in Portugal: Spatial determinants in a context of economic crisis

This study compares the existing statistical association between suicide mortality and the characteristics of places of residence (municipalities), before and during the current economic crisis, in Portugal. We found that (1) the traditional culture-based North/South pattern of suicidal behaviour has faded away, while the socioeconomic urban/rural divide has become more pronounced; (2) suicide is associated with higher levels of rurality and material deprivation; and (3) recent shifts in suicidal trends may result from the current period of crisis. Strategies targeting rural areas combined with public policies that address area deprivation may have important implications for tackling suicide.

Trend of Suicide Rates According to Urbanity among Adolescents by Gender and Suicide Method in Korea, 1997-2012

This study aims to quantifiably evaluate the trend of the suicide rate among Korean adolescents from 1997 to 2012 according to urbanity. We used national death certificates and registration population data by administrative district for 15–19 years-old adolescents. The annual percent change (APC) and average annual percent change (AAPC) were estimated by the Joinpoint Regression Program. The suicide rate in the rural areas was higher than that in the urban areas in both genders (males (/100,000), 12.2 vs. 8.5; females (/100,000), 10.2 vs. 7.4 in 2012). However, the trend significantly increased only in the urban area (AAPC [95% CI]: males 2.6 [0.7, 4.6], females 3.3 [1.4, 5.2]). In urban areas, the suicide rate by jumping significantly increased in both genders (AAPC [95% CI]: males, 6.7 [4.3, 9.1]; females, 4.5 [3.0, 6.1]). In rural areas, the rate by self-poisoning significantly decreased by 7.9% per year for males (95% CI: −12.5, −3.0) and the rate by hanging significantly increased by 10.1% per year for females (95% CI: 2.6, 18.2). The trend and methods of suicide differ according to urbanity; therefore, a suicide prevention policy based on urbanity needs to be established for adolescents in Korea.

Feasibility of internet-delivered mental health treatments for rural populations

PURPOSE

Rural populations face numerous barriers to mental health care. Although internet-delivered mental health treatments may offer an accessible and cost-effective answer to these barriers, there has been little evaluation of the feasibility of this approach among rural communities.

METHODS

Data were obtained from a random rural community sample through the third wave of the Australian Rural Mental Health Study. Attitudes towards internet-delivered mental health treatments and availability of internet access were explored. Data were analysed to identify sub-groups in whom internet-delivered treatments may be usefully targeted.

RESULTS

Twelve hundred and forty-six participants completed the survey (mean age 59 years, 61% females, 22% from remote areas). Overall, 75% had internet access and 20% would consider using internet-based interventions, with 18% meeting both of these feasibility criteria. Logistic regression revealed feasibility for internet-delivered mental health treatment was associated with younger age, male gender, being a carer, and a 12-month mental health problem. Participants who had used internet-delivered services in the past were significantly more likely to endorse these treatments as acceptable.

CONCLUSIONS

There is considerable potential for internet-delivered treatments to increase service accessibility to some sub-groups, particularly among people with mental health problems who are not currently seeking help. Resistance to internet treatments appears to be largely attitudinal, suggesting that enhancing community education and familiarity with such programs may be effective in improving perceptions and ultimately access.

Northern excess in adolescent male firearm suicides: a register-based regional study from Finland, 1972-2009

There are more firearms in Northern Finland as compared to Southern Finland, and a positive association between suicide rates and the number of firearms in a given region has been demonstrated in previous literature. Accordingly, the authors compared firearm suicide rates of Finnish adolescent (under 18 years) males in the two geographic regions. Young adult (18-24 years) and adult (25-44 years) males were used as reference groups. National data on cases of suicide in Northern and Southern Finland between 1972 and 2009 were obtained from Statistics Finland. Firearm suicides (n=5,423) were extracted according to ICD-classification (ICD-8/9: E955, ICD-10: X72-X75). The distribution of types of firearms (hunting gun, handgun, other) employed in suicides was also investigated. The adolescent male firearm suicide rate in Northern Finland was almost three times higher than that observed in Southern Finland, while there was no difference in rates of suicide by other methods. A northern excess in firearm suicide rates was also found among young adult and adult males. Hunting guns were the most common type of firearms employed in young male suicides, and their use was especially common in Northern Finland. Our results indicate that the use of firearms plays a major role in explaining the northern excess in young Finnish male suicide rates, and emphasize a need to advance suicide prevention according to specific regional characteristics.

Spatial clusters of suicide in Australia

BACKGROUND

Understanding the spatial distribution of suicide can inform the planning, implementation and evaluation of suicide prevention activity. This study explored spatial clusters of suicide in Australia, and investigated likely socio-demographic determinants of these clusters.

METHODS

National suicide and population data at a statistical local area (SLA) level were obtained from the Australian Bureau of Statistics for the period of 1999 to 2003. Standardised mortality ratios (SMR) were calculated at the SLA level, and Geographic Information System (GIS) techniques were applied to investigate the geographical distribution of suicides and detect clusters of high risk in Australia.

RESULTS

Male suicide incidence was relatively high in the northeast of Australia, and parts of the east coast, central and southeast inland, compared with the national average. Among the total male population and males aged 15 to 34, Mornington Shire had the whole or a part of primary high risk cluster for suicide, followed by the Bathurst-Melville area, one of the secondary clusters in the north coastal area of the Northern Territory. Other secondary clusters changed with the selection of cluster radius and age group. For males aged 35 to 54 years, only one cluster in the east of the country was identified. There was only one significant female suicide cluster near Melbourne while other SLAs had very few female suicide cases and were not identified as clusters. Male suicide clusters had a higher proportion of Indigenous population and lower median socio-economic index for area (SEIFA) than the national average, but their shapes changed with selection of maximum cluster radii setting.

CONCLUSION

This study found high suicide risk clusters at the SLA level in Australia, which appeared to be associated with lower median socio-economic status and higher proportion of Indigenous population. Future suicide prevention programs should focus on these high risk areas.

Ecological study of isolation and suicide in Tuscany (Italy)

The purpose of the study was to investigate the association between suicide and demographic and socio-economic measures in Tuscany. Data on standardized rates of suicide from 1997 to 2005 in addition to census-derived variables, income and abstention were derived from the Mortality register, the 2001 Census, the Tax Agency and the Regional Electoral Office databases. Pearson's correlation and stepwise multiple regression analyses (unweighted and weighted by population) were used to analyze the association between suicide rates and demographic and socio-economic measures for the 34 health districts for both males and females. The correlation analyses showed that suicide was significantly associated with many variables in men, but only with old age in women. The multiple regression analyses showed that the best predictors in men were education, single person households and isolated houses (only education and single person households in the weighted model). For women, the best predictors were the proportion of elderly people and income (this was also true for the weighted model, but in the opposite order). An ecological correlation between suicide and measures of economic deprivation and social fragmentation was found in both men and women. Among the best predictors, isolated houses may act as a marker for remoteness and isolation on a small scale.

Suicide in young men

Suicide is second to only accidental death as the leading cause of mortality in young men across the world. Although suicide rates for young men have fallen in some high-income and middle-income countries since the 1990s, wider mortality measures indicate that rates remain high in specific regions, ethnic groups, and socioeconomic groups within those nations where rates have fallen, and that young men account for a substantial proportion of the economic cost of suicide. High-lethality methods of suicide are preferred by young men: hanging and firearms in high-income countries, pesticide poisoning in the Indian subcontinent, and charcoal-burning in east Asia. Risk factors for young men include psychiatric illness, substance misuse, lower socioeconomic status, rural residence, and single marital status. Population-level factors include unemployment, social deprivation, and media reporting of suicide. Few interventions to reduce suicides in young men have been assessed. Efforts to change help-seeking behaviour and to restrict access to frequently used methods hold the most promise.

Suicide among patients in the Veterans Affairs health system: rural-urban differences in rates, risks, and methods

OBJECTIVES

Using national patient cohorts, we assessed rural-urban differences in suicide rates, risks, and methods in veterans.

METHODS

We identified all Department of Veterans Affairs (VA) patients in fiscal years 2003 to 2004 (FY03-04) alive at the start of FY04 (n = 5,447,257) and all patients in FY06-07 alive at the start of FY07 (n = 5,709,077). Mortality (FY04-05 and FY07-08) was assessed from National Death Index searches. Census criteria defined rurality. We used proportional hazards regressions to calculate rural-urban differences in risks, controlling for age, gender, psychiatric diagnoses, VA mental health services accessibility, and regional administrative network. Suicide method was categorized as firearms, poisoning, strangulation, or other.

RESULTS

Rural patients had higher suicide rates (38.8 vs 31.4/100,000 person-years in FY04-05; 39.6 vs 32.4/100,000 in FY07-08). Rural residence was associated with greater suicide risks (20% greater, FY04-05; 22% greater, FY07-08). Firearm deaths were more common in rural suicides (76.8% vs 61.5% in FY07-08).

CONCLUSIONS

Rural residence is a suicide risk factor, even after controlling for mental health accessibility. Public health and health system suicide prevention should address risks in rural areas.

Effectiveness of Australian youth suicide prevention initiatives

BACKGROUND

After an epidemic rise in Australian young male suicide rates over the 1970s to 1990s, the period following the implementation of the original National Youth Suicide Prevention Strategy (NYSPS) in 1995 saw substantial declines in suicide in young men.

AIMS

To investigate whether areas with locally targeted suicide prevention activity implemented after 1995 experienced lower rates of young adult suicide, compared with areas without such activity.

METHOD

Localities with or without identified suicide prevention activity were compared during the period of the NYSPS implementation (1995-1998) and a period subsequent to implementation (1999-2002) to establish whether annual average suicide rates were lower and declined more quickly in areas with suicide prevention activity over the period 1995-2002.

RESULTS

Male suicide rates were lower in areas with targeted suicide prevention activity (and higher levels of funding) compared with areas receiving no activity both during (RR = 0.89, 95% CI 0.80-0.99, P = 0.030) and after (RR = 0.86, 95% CI 0.77-0.96, P = 0.009) implementation, with rates declining faster in areas with targeted activity than in those without (13% v. 10% decline). However, these differences were reduced and were no longer statistically significant following adjustment for sociodemographic variables. There was no difference in female suicide rates between areas with or without targeted suicide prevention activity.

CONCLUSIONS

There was little discernible impact on suicide rates in areas receiving locally targeted suicide prevention activities in the period following the NYSPS.

The acceptability of suicide among rural residents, urban residents, and college students from three locations in China: a cross-sectional survey

BACKGROUND

Community attitudes about suicide and their relationship to suicidal behavior have not been adequately investigated in low- and middle-income countries.

AIMS

To compare the acceptability of suicide in different population cohorts in China, identify factors that affect the degree of acceptability, and assess the relationship of cohort-specific acceptability of suicide and suicide rates.

METHODS

A multistage stratified random sample of 608 rural residents, 582 urban residents, and 629 college students were administered a 25-item scale studying the likelihood they would consider suicide (on a 5-point Likert scale) if they experienced a variety of stressors ranging from "being disciplined at work" to "developing a chronic mental illness." The internal consistency and test-retest reliability for the scale are excellent (Cronbach's alpha = 0.92, ICC = 0.75).

RESULTS

College students had the most permissive attitudes about suicide, and urban residents were significantly more accepting of suicide as a response to serious life stressors than were rural residents. Multivariate analysis found that the overall acceptability score was higher in women, decreased with age, and increased with years of education.

CONCLUSIONS

There was no clear relationship between cohort-specific acceptance of suicide and reported rates of suicide, highlighting the complexity of the relationship between attitudes about suicide (of which acceptability is only one component) and suicidal behavior.

Prison inmates' suicidal ideation in China: a study of gender differences and their impact

Suicide is one of the leading causes of inmate death, and many studies have explored suicidal risks among inmates in Western countries. Such studies, however, have been extremely rare in China. Because of China's unique cultural and social conditions, suicide displays many distinctive features and one of them is the greater percentage of women (than men) who commit suicide. With data collected from three adult prisons in China, this study tests gender differences on prison inmates' suicidal risk factors and explores the correlation of gender's impact with other factors. Findings show that male and female inmates present distinctive patterns of suicidal ideation, although gender fails to exert a significant direct impact on the outcome. The results call for different approaches and treatments toward both gender groups for suicide prevention in Chinese correctional facilities.

Young rural people at risk for schizophrenia: time for mental health services to translate research evidence into best practice of care

Early intervention into prodromal schizophrenia has shown promise, but controversy continues regarding the ethical acceptability of identifying a group of 'ultra high risk' individuals of whom only 30 to 50% will develop a psychotic disorder. With well developed early intervention services this group faces the possibility of being labelled as 'pre-psychotic', a condition for which the well known stigma associated with the diagnosis of schizophrenia or bipolar disorder is likely to be associated. In addition, the use of potent antipsychotic and other medications (albeit usually at lower doses than those used for those with manifest psychosis) mandates consideration of the risks associated with their use and neurological and metabolic side effects. The potential for iatrogenic morbidity in the 'false positive' group must be weighed against the need of the 'true positives' identified through screening and assessment. Current evidence for the concept of 'at-risk mental state' was reviewed within a neurodevelopmental framework, including emerging data on the effectiveness of early intervention for the purpose of providing recommendations for community mental health services. The review suggests that different treatment strategies may be appropriate depending on the clinical stage of the condition as long as the benefits of intervention outweigh its risk burden. It further suggests that the severity of psychoses and the evidence of its early onset in utero and its acceleration in adolescence positions 'ultra high risk' intervention as a core model for early intervention for young people by teasing apart the symptomatic components of the 'prepsychotic state' and ensuring the population is reaching targeted mental health services for screening. The model is not restricted to the delivery of intervention for 'pre-psychotic' young people but is applicable for targeted programmes for a number of clinical groups considered at 'ultra high risk'. However, only further research in naturalistic populations embedded in clinical practice and ideally conducted in partnership of mental health services with academic research institutions will help clarify potential risks of early identification and intervention and assist in updating and making more explicit the clinical guidelines services will use in approaching those in the 'ultra high risk' group.

Rural-urban differences in suicide rates for current patients of a public mental health service in Australia

Rural versus urban rates of suicide in current patients of a large area mental health service in Australia were compared. Suicide deaths were identified from compulsory root cause analyses of deaths, 2003-2007. Age-standardized rates of suicide were calculated for rural versus urban mental health service and compared using variance of age-standardized rates with 95% confidence intervals. There were 44 suicides and the majority (62%) were rural. Only urban patients used jumping from heights as a method of suicide (4/17; p = 0.02). Rural patients had 2.7 times higher rates of suicide, similar to findings for rural versus urban community suicides and may reflect the underlying community rates, differences in mental health service delivery, or socioeconomic disadvantage.

Recent declines in Australian male suicide are real, not artefactual

OBJECTIVES

The aim of the present study was to clarify the extent to which the recorded marked decline in young male suicide (20-34 years) in Australia since 1998 is attributable to misclassification of cause of death information.

METHODS

Secular trends in young male suicide rates were investigated for the period 1976-2005. Suicide rates in the period after the peak of the epidemic in this age group (1998) were re-calculated based on published estimates of under-enumeration of suicide data, and misclassification of likely suicide cases to other unintentional and undetermined external causes. Two misclassification scenarios were used to revise young male suicide rates from 1998: previously reported estimates of 9% under-enumeration due to misclassification of unintentional causes of death, and 17% under-enumeration due to misclassification of open cases in addition to unintentional causes of death. All-cause mortality was also examined.

RESULTS

Recorded male suicide in the 20-34 year age group increased over the study period, peaking in 1998 at 39 per 100,000, before declining sharply in the period 1999-2005 by 44% to 22 per 100,000 in 2005. Following adjustment for misallocation under the first scenario, suicide rates declined 38% to 24 per 100,000, and under the second scenario declined 33% to 26 per 100,000. Revised suicide rates were not materially different from recorded suicide rates based on 95% confidence intervals over this period. All-cause mortality declined from 1999 due to reductions in suicide and other causes.

CONCLUSION

The recent marked decline in young male suicide in Australia is real. The effects of misallocation of likely suicide cases to other causes did not substantially affect population trends in suicide rates in the period after 1998. There is still a need to account in detail for why young male suicide has declined so substantially during the period after 1998.

Correlates of comorbid mental disorders in a regional community-based sample

OBJECTIVE

The common coexistence of psychiatric disorders has been identified as a significant factor contributing to the disability associated with mental illness. Identifying indicators to the development of coexisting disorders has potential clinical implications. This study aimed to investigate the correlates and impact of coexisting disorders in a rural setting.

DESIGN

Cross-sectional analyses of data from a cohort interviewed in two phases.

SETTING

A regional community sample in Northern New South Wales, Australia.

PARTICIPANTS

A total of 1407 participants were interviewed and 968 were re-interviewed at follow up.

MAIN OUTCOME MEASURES

Multinomial logistic regression modelling compared subjects with multiple psychiatric disorders with those with a single disorder for sociodemographic characteristics, measures of personal and social vulnerability, psychological distress, functional disabilities and help-seeking behaviours.

RESULTS

Participants with coexisting disorders were more likely to be male, report a history of severe childhood assault and had higher levels of neuroticism, psychological distress and help-seeking behaviour.

CONCLUSIONS

The findings suggest the role of early developmental factors on the complexity and severity of adult mental illness in a rural setting and the significant clinical consequences of comorbidity.

Évolution du suicide au Québec

Après la hausse observée au cours des années 1990, de récentes constatations suggèrent que les taux de suicide ont commencé à diminuer. La présente analyse tente d’identifier les années où se sont produits des changements significatifs dans la tendance de la mortalité par suicide au Québec au cours de la période 1981 à 2005 selon l’âge, le sexe et le milieu géographique. Un modèle de régression Joinpoint a été utilisé pour évaluer les changements dans la tendance. Nos résultats montrent que les taux de suicide se sont infléchis à la fin des années 1990. Depuis, les taux de suicide diminuent, plus rapidement chez les hommes, plus spécialement ceux âgés de 15 à 34 ans. Cette baisse s’observe plus particulièrement dans la région métropolitaine de recensement de Montréal, alors que pour le monde rural, les changements sont moins évidents. D’autres recherches sont nécessaires pour identifier les facteurs associés à cette baisse.

Sociodemographic correlates of antidepressant utilisation in Australia

OBJECTIVE

To investigate sociodemographic variation in antidepressant utilisation.

DESIGN AND SETTING

Cross-sectional analysis of antidepressant prescription under the Pharmaceutical Benefits Scheme in Australia, 2003-2005.

MAIN OUTCOME MEASURES

Antidepressant utilisation (defined daily dose/1000/day) by sex, age, socioeconomic status (SES) and geographical area.

RESULTS

Total antidepressant utilisation increased with age. Among those aged > or = 15 years, female utilisation was about double that of males. About half of antidepressant utilisation was accounted for by sertraline, venlafaxine, citalopram, and paroxetine. SES differentials in antidepressant utilisation changed across age groups for males and females: among those aged < or = 19 years, total antidepressant utilisation was significantly less in lower SES groups (P < 0.001); there was no relationship to SES among 20-29-year-olds; and among those aged > or = 30 years, antidepressant utilisation was significantly higher in lower SES groups (P < 0.001). SES differences were attenuated after adjusting for urban or rural residence, but remained statistically significant. Antidepressant utilisation rates were highest in regional centres.

CONCLUSION

Antidepressant utilisation in Australia partially reflects sociodemographic differences in the prevalence of affective disorder. Discrepancies between treatment provision and treatment need suggest that not all social strata in Australia have equal access to these treatments.

Unravelling the extent of inequalities in health across urban and rural areas: evidence from a national sample in England

Studies of inequalities in health between rural and urban settings have produced mixed and sometimes conflicting results, depending on the national setting of the study, the level of geographic detail used to define rural areas and the health indicators studied. By focusing on morbidity data from a national sample of individuals, this study aims to examine the extent of inequalities in health between urban and rural areas, as well as inequalities in health across rural areas of England. Multilevel analyses for poor self-rated health, overweight and obesity, and common mental disorders are reported for a sample of 30,776 individuals aged 18 years and older (obtained from the Health Survey for England years 2000-2003 combined) and distributed across 3645 small areas classed in four categories: two groups of urban areas (Greater London area or 'other cities') and two types of rural settings (semi-rural areas or villages). Results show that rural dwellers were significantly less likely than residents of urban areas to report their health as being fair or poor and to report common mental disorders, independent of their socio-demographic characteristics. However, as for urban settlements, there were significant variations in health across semi-rural areas and across villages, indicating the presence of health inequalities within rural settings in England. These inequalities were not fully explained by the individual composition of the areas or by the available measures of area socioeconomic conditions, indicating that in rural contexts more specific factors may have significance for health. Different policies and services for health promotion and care may need to be targeted to different types of rural areas.